Nokea
The pediatric nurse is being pulled to the nursery for the day. The census is six neonates. Which 3 neonates are the best client care assignment for the pediatric nurse?? Select all that apply:
- A. An 18-hour post term, breast-fed neonate with jaundice
- B. A 2-day old who has not passed a meconium stool
- C. A recent admission with Apgar score of 8 out of 10
- D. A 1-day-old with caput succedaneum
Correct Answer: A
Rationale: - A. An 18-hour post-term, breast-fed neonate with jaundice would be a good assignment for the pediatric nurse because a neonate with jaundice requires close monitoring of bilirubin levels and feeding patterns. Breastfeeding can also affect jaundice levels, so the nurse can provide education and support to ensure successful breastfeeding and manage jaundice effectively.
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A nurse is assessing a newborn immediately following a vaginal birth. For which of the following findings should the nurse intervene?
- A. Molding
- B. Vernix Caseosa
- C. Acrocyanosis
- D. Sternal retractions
Correct Answer: D
Rationale: Sternal retractions in a newborn may indicate respiratory distress or difficulty breathing. It is important for the nurse to intervene and assess the newborn's respiratory status further as this finding could be a sign of underlying respiratory issues that require immediate attention. The nurse should monitor the newborn's oxygen saturation, respiratory rate, and any other signs of distress to ensure appropriate intervention is provided promptly.
A client comes to the labor and delivery with polyhydramnios. She was admitted and her membrane ruptures is clear and odorless, but the fetal heart monitor indicate bradycardia and variable decelerations. What should action should be taken next?
- A. Perform vaginal exam (lot of fluid, check to see where baby is)
- B. High fowler position
- C. Warm saline soak vaginal
- D. Perform Leopold maneuver
Correct Answer: A
Rationale: In this scenario, with the presence of polyhydramnios and clear, odorless amniotic fluid, the fetal heart monitor indicating bradycardia and variable decelerations indicates a potential umbilical cord compression due to excessive amniotic fluid volume. It is crucial to perform a vaginal exam promptly as this can help assess the position of the baby and determine if there is a cord prolapse or any other complications that may be affecting the fetal heart rate. The baby's position needs to be identified quickly to address potential issues and ensure a safe delivery process.
A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take?
- A. Decrease the rate of infusion of the maintenance IV solution.
- B. Discontinue the infusion of the IV oxytocin.
- C. Increase the rate of infusion of the IV oxytocin.
- D. Slow the client's rate of breathing.
Correct Answer: B
Rationale: The described scenario suggests the presence of late decelerations, which occur when uteroplacental insufficiency leads to decreased fetal oxygenation. In this case, the late decelerations are evident with each contraction, indicating a potential adverse reaction to the oxytocin infusion. The appropriate action would be to discontinue the infusion of IV oxytocin to prevent further compromise to fetal well-being. Alternatively, the nurse should consider repositioning the mother, administering oxygen via a face mask, and notifying the healthcare provider for further assessment and interventions.
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors paces the client at risk for infection.
- A. Meconium "“ start fluid
- B. Placenta previa
- C. Midline episiotomy
- D. Gestational hypertension
Correct Answer: C
Rationale: A midline episiotomy increases the risk for infection in postpartum clients due to the incision made in the perineum during childbirth. This incision can serve as a portal of entry for microorganisms, leading to an increased risk of infection. Meconium-stained amniotic fluid (choice A) can increase the risk of respiratory distress in the newborn but is not directly related to infection in the postpartum client. Placenta previa (choice B) is a condition during pregnancy where the placenta partially or completely covers the cervix, which poses risks related to bleeding rather than infection postpartum. Gestational hypertension (choice D) is a risk factor for developing preeclampsia or eclampsia during pregnancy but does not directly increase the risk of infection in the postpartum period.
A male infant delivered at 28 weeks gestation weighs 2 pounds, 12 ounces. When performing an assessment, the nurse would probably observe:
- A. Wide, staring eye
- B. Transparent, red skin
- C. An absence of lanugo
- D. A scrotum with descended testicles
Correct Answer: B
Rationale: A male infant delivered at 28 weeks gestation, as described, would likely have very underdeveloped skin due to the premature birth. The premature skin is often transparent, allowing the prominent blood vessels underneath to be visible, and may also have a reddish hue due to the skin's immaturity. This characteristic appearance is a common finding in premature infants and is a result of their skin being thinner and more fragile than that of full-term infants. The other options, such as a wide, staring eye, an absence of lanugo, and a scrotum with descended testicles, are not specifically associated with premature birth and are not likely to be observed in this scenario.